Influence of operative timing on prognosis of patients with acute subdural hematoma

Objective: To study the influence of operative timing on the prognosis of patients with acute subdural hematoma (ASDH) in order to provide theoretical basis for clinical treatment.Methods: The clinical data of 202 patients with ASDH undergoing operations were collected, and the mortalities and functional survival rates were analyzed 2, 4, 6, and 8 hours after injury.Results: No significant difference was found in mortalities and functional survival rates at different operative timings. However, there was a clear trend that the shorter the operative timing was, the lower the mortality and the higher functional survival rate were. In addition, the mean time from injury to operation of non-survivors was significantly longer than that of survivors.Conclusions: Operative timing has potential influences on the prognosis of patients with ASDH. Surgical evacuation of ASDH should be performed as soon as possible once the operation indication emerges.     

急性硬膜下血肿手术时机对预后的影响

目的 研究手术时机对急性硬膜下血肿预后的影响.方法 收集了202例接受手术治疗的急性硬膜下血肿患者,统计分析伤后2、4、6、8h等时间为界限的死亡率和功能生存率.结果 各个时间界限的死亡率和功能生存率差异无统计学意义,但是随着受伤至手术间隔时间的延长,死亡率呈现出逐渐增加、功能生存率逐渐降低的趋势.并且,死亡患者的受伤至手术时间要显著大于生存患者.结论 急性硬膜下血肿手术时机对预后有潜在的影响.符合有手术指征的患者,急性硬膜下血肿需要尽早手术清除血肿.     

Traumatic subdural hydroma developing into chronic subdural hematoma

Objective: To probe the incidence, pathogenesis and clinical characteristics of traumatic subdural hydroma (TSH) developing into chronic subdural hematoma(CSDH). Methods: We retrospectively analyzed the clinical data of 32 patients with TSH developing into CSDH and reviewed related literature. Results: 16.7 % of TSH developed into CSDH in this study. The time of evolution was from 22 to 100 days after head injury. All the patients were cured with hematoma drainage. Conclusions : TSH is one of the origins of CSDH. The clinical characteristics of TSH developing into CSDH follow that the ages of the patients are polarized, that the evolution often happens in the patients with small chronic hydromas and being treated conservatively, that the patients are usually injured deceleratedly and that the accompanying cerebral damage is often very mild.     

外伤性硬膜下积液演变的慢性硬膜下血肿

目的 探讨外伤性硬膜下积液演变为慢性硬膜下血肿的几率、机理和临床特点。方法 回顾性分析32例外伤性硬膜下积液演变为慢性硬膜下血肿患者的临床资料及有关文献。结果 本组16.7%的外伤性硬膜下积液病例演变为慢性硬膜下血肿;积液演变为血肿的时间为伤后22－100d;经钻颅血肿引流均治愈。结论 外伤性硬膜下积液是慢性硬膜下血肿的来源之一。发病年龄两极化,常发生在积液量少、保守治疗的慢性型病例中,致病方式常为减速性损伤及合并的颅脑损伤很轻微是外伤性硬莫膜下积液演变为慢性硬膜下血肿患者的临床特点。     

重症急性胰腺炎手术时机和手术方式的探讨

目的 探讨重症急性胰腺炎(SAP)手术时机和手术方式。方法 对1986~1998年收治的59例SAP患者手术时机、术式及病死率进行回顾性分析。结果 (1)手术病死率为20.3%,其中66.7%为40~60岁患者。性别及病因分类无差异。1992年以前早期手术为主,病死率26.7%,并发症发生率40.0%;1992年以后延期手术为主,病死率13.8%,并发症发生率24.1%。(2)随手术距发病时间延长,病死率逐渐降低,但差异无显著性(P>0.05)。(3)随胰腺坏死程度增加,手术病死率显著增加(P<0.05)。(4)休克、Ⅲ级胰坏死及多脏器功能衰竭的相关病死率分别为42.9%、40.0%和71.4%(P均<0.05)。(5)术式以胆胰联合手术及单纯胰病灶清除引流为主。结论 SAP手术时机是影响手术病死率的重要因素,应采用延期与个体化相结合的处理原则。术式选择应以简单有效,充分引流,清除病灶,去除病因为基本原则。     

Iatrogenic acute subdural hematoma due to drainage catheter

BACKGROUND

Insertion of a catheter for drainage of a cavity is a routine step in many surgical practices. In neurosurgery, catheters are commonly placed in the subdural, subgaleal, or epidural spaces to prevent haematoma formation.

CASE DESCRIPTION

We present three cases of iatrogenic acute subdural hematoma. These were all related to the drainage catheters. In the first case, a subgaleal redivac suction catheter was used after craniotomy for brain abscess. The other two patients had ordinary ventricular catheters placed in the subdural space after burr hole drainage of chronic subdural hematoma. The drainage catheter was removed on postoperative day 5 in the first case and two days after the initial operation in the other two cases. Shortly after the removal of the drains, the conditions of the patients deteriorated rapidly due to the development of acute subdural hematoma.

CONCLUSION

Although they are extremely uncommon, life-threatening complications related to a drainage catheter are a real possibility. Therefore, the procedure should not be taken lightly.     

急性硬膜下血肿清除术后迟发性硬膜下积液的诊治

目的 探讨急性硬膜下血肿清除术后硬膜下积液的原因、早期诊断、手术治疗方法和疗效。方法 对急性硬膜下血肿后硬膜下积液29例进行回顾性分析。结果 痊愈14例，占48．7％；轻残5例，占17．2％；重残4例，占13．8％；植物状态3例，占10．3％，死亡3例，占10．3％。引流效果良好，无一例颅内感染。结论 急性硬膜下血肿清除后可能发生硬膜下积液；术后意识无改善或意识好转后又加重、出现颅内压增高征象、神经系统定位体征、减压区膨隆、瞳孔及生命体征改变应予CT检查可明确诊断：积液区颅骨钻孔或减压区小切口置管引流简便易行，有效满意疗效。     

重症胰腺炎手术时机和手术方式的选择

目的探讨重症胰腺炎（ＳＡＰ）最佳手术时机和手术方式。方法对１９８５年～１９９４年间收治的５０例ＳＡＰ患者手术时机、术式及病死率进行回顾性分析。结果（１）手术病死率为１４％,其中８５．７％为４０～６０岁年龄段患者。性别及病因分类无差异。（２）随手术距发病时间延长,病死率逐渐降低,但差异无显著性（Ｐ＞０．０５）。（３）随手术距入院时间延长,病死率明显降低,入院１２小时内手术者病死率显著高于其他时间组（Ｐ＜０．０１）。（４）随胰坏死程度及胰外器官受累个数增加,手术病死率显著增加（Ｐ＜０．０１及Ｐ＜０．０５）。（５）休克、胰坏死及多脏器功能衰竭（ＭＯＦ）的相关病死率分别为３１．８％、３１．６％和２８．０％（Ｐ均＜０．０５）。（６）术式以胆胰联合手术及单纯胰病灶清除引流为主。结论ＳＡＰ手术时机是影响手术病死率的重要因素,最佳时机的选择应与ＳＡＰ自然病程相适应,避免在发病后１～７天,尤其在入院１２小时内手术。强调术前给予至少２４小时支持治疗。术式选择应以简单有效,充分引流,清除病灶,去除病因为基本原则。     

外伤性硬膜下积液的分型与临床特点

目的　探讨外伤性硬膜下积液的分型及其临床特点。　方法　对 192例资料完整的外伤性硬膜下积液患者 ,根据其动态CT观察及临床症状、体征进行分型 ,分别为消退型、稳定型、进展型和演变型 ,并对其临床特点进行总结、分析。　结果　消退型以青壮年多见 ,一般无明显颅内压增高 ,采取保守治疗 ,预后好 ;稳定型以老年人占多数 ,头痛、头晕、恶心、呕吐、精神异常 (欣快、淡漠、抑郁等 )、记忆力下降为主要表现 ,一般无与硬膜下积液相关的神经系统阳性体征 ,经非手术治疗 ,预后亦较好 ;进展型多为小儿患者 ,主要表现为进行性颅内压增高 ,可有轻度偏瘫、失语或精神异常等表现 ,多需外科治疗 ,可因合并脑实质损伤或术后并发症而有一定病死率 ;演变型呈发病年龄两极化 ,常发生在积液后 2 2～ 10 0d而且积液量少、保守治疗的病例中 ,合并的颅脑损伤常常很轻微 ,慢性颅内压增高 ,经外科治疗 ,预后良好。　结论　不同类型的外伤性硬膜下积液的发生机理、临床表现、治疗方法和预后各不相同 ,临床治疗策略也应不同。     

Oculomotor palsy with pupillary sparing in a patient with chronic subdural hematoma

A patient with adult-onset diabetes mellitus developed an oculomotor palsy with pupillary sparing. Five days after her initial evaluation, she presented in a confused state with a complete oculomotor palsy. Computed cranial tomography revealed a chronic subdural hematoma. We recommend that noninvasive radiographic intracranial investigation be considered in elderly patients with adultonset diabetes mellitus who present with headache and pupil-sparing oculomotor palsy.     

Endoscopic removal of organized chronic subdural hematoma

An endoscopic surgical approach to organized chronic subdural hematoma is described. Advantages of the endoscopic approach include access to virtually the entire hematoma cavity through a small craniectomy performed with local-standby anesthesia. Two illustrative cases are presented.     

急性硬脑膜下血肿患者的生存率与血肿厚度、中线移位的关系

目的：分析急性硬脑膜下血肿的血肿厚度、中线移位及其差值在判断患者预后中的作用。方法：回顾性收集并分析95例急性硬脑膜下血肿患者的临床资料,计算血肿厚度、中线移位及其差值,用Kaplan-Meier、Wilcoxon-Mann-Whitney U检验分析它们与预后的关系。结果：本组患者血肿厚度5-40mm、中线移位0-35mm,两者差值-20-35mm;48例（51％）死亡,47例（49％）存活,存活患者中18例（19％）预后良好。Kaplan-Meier分析显示：血肿厚度在17.0mm、中线移位在15.0mm、中线移位超过血肿厚度2.2mm的患者生存率为50％;预后与这些因素之间有显著的相关性。结论：血肿厚度、中线移位及两者差值是判断急性硬脑膜下血肿患者预后的关键因素,并可作为指导临床治疗的依据。     

老年退变性腰椎间盘病的临床特征和手术治疗

退变性腰椎间盘病是老年人腰腿痛最常见病因，病情较复杂常合并其他疾病，因此在诊治上有其特殊性。回顾性分析1990年1月-2001年12月手术治疗266例老年患者。     

胸段食管鳞状细胞癌外科治疗与预后分析

目的 探讨胸段食管鳞状细胞癌切除术后生存率的影响因素.方法 回顾性分析1990年1月至1998年12月716例胸段食管鳞状细胞癌手术患者的临床病理资料,其中男性538例,女性178例;年龄24-78岁,中位年龄57岁.应用Kaplan-Meier法进行生存分析,组间比较用Logrank检验,采用COX模型进行多因素分析.结果 总的1、3、5和10年生存率分别为82.9%、44.3%、34.2%和25.7%.Ⅰ期、ⅡA期、ⅡB期和Ⅲ期患者的5年生存率分别为80.0%、51.2%、19.7%和13.3%.术后复发转移151例,占21.1%;其中ⅡA期、ⅡB期和Ⅲ期复发患者3年内复发率分别为84.2%、91.7%和90.O%.单因素分析表明性别、肿瘤浸润深度、淋巴结转移、病理分期、淋巴结转移区域数、组织分化、手术切缘和肿瘤复发均为预后影响因素.多因素分析显示肿瘤浸润深度、淋巴结转移、病理分期和肿瘤复发是食管癌预后的独立影响因素.结论 胸段食管鳞状细胞癌患者术后生存率的独立影响因素有肿瘤浸润深度、淋巴结转移、病理分期和肿瘤复发.手术是Ⅰ-ⅡA期食管癌的主要治疗方法,ⅡB-Ⅲ期食管癌应采用以手术为主的综合治疗.     

Acute subdural hematoma: morbidity and mortality related to timing of operative intervention

In spite of major advances in the management of severe head injury (HI) acute subdural hematoma (ASDH) continues to be one of the most lethal of all intracranial injuries. Of 1,150 consecutive severe HI patients, 137 (12%) had ASDH. The following variables were assessed in regards to outcome morbidity/mortality from ASDH: mechanism of injury, age, sex, neurologic presentation, postoperative intracranial pressure (ICP), and timing from injury to operative evacuation of the ASDH. The only variables found to statistically correlate with outcome were presenting neurologic condition (p = 0.001) and elevated postoperative ICP greater than 45 mm Hg (p = 0.001). The timing from injury to operative evacuation of the ASDH in regards to outcome morbidity/mortality was not statistically significant even when examined at hourly intervals (p = 0.418).     

Prognostic factors in severely head injured adult patients with acute subdural haematoma's

Summary A medline search back to 1975 was undertaken to identify relevant papers published on subdural haematomas. The search was restricted, whenever possible, to adult age and comatose patients. Forty relevant reports were identified. Only 3 papers reported results on multivariate analysis. In terms of prognosis, the following parameters were found to be significant: age, time from injury to treatment, presence of pupillary abnormalities, GCS/motor score on admission, immediate coma or lucid interval, CT findings (haematoma volume, degree of midline shift, associated intradural lesion, compression of basal cisterns), post-operative ICP and the type of surgery. Improving the outcome of patients with acute subdural haematoma's is a difficult task. A small subpopulation of patients may have a benign course without surgical haematoma evacuation, but all comatose patients with an acute subdural haematoma should be treated in Centers where neurosurgical facilities and appropriate monitoring are available.     

Significance of consecutive bilateral surgeries for patients with acute subdural hematoma who develop contralateral acute epi- or subdural hematoma

BACKGROUND: Although rare, patients with acute subdural hematoma (ASDH) because of severe head injury can develop contralateral acute epi- or subdural hematoma, requiring consecutive surgical procedures. The choice of treatment strategies for such patients is clinically important. METHODS: Among 88 patients with ASDH who were surgically treated over 13 years, we encountered and studied 5 patients who developed contralateral acute epi- or subdural hematoma (5.7%). RESULTS: All 5 patients were male, ranging in age from 17 to 40. According to the Glasgow Coma Scale on admission, 1 patient was rated 3, 1 was 4, 1 was 5, and 2 were 6. All patients underwent consecutive surgical procedures for ASDH and contralateral ASDH and/or acute epidural hematoma, and were given postoperative supportive therapy with barbiturates and mild hypothermia. Patients' outcomes according to the Glasgow Outcome Scale were as follows: 1 patient, good recovery (20.0%); 1, mild disability (20.0%); 2, severe disability (40.0%), and 1, persistent vegetative state (20.0%). No patients died. Although decompressive craniectomy and evacuation of hematoma may lead to contralateral acute epi- or subdural hematoma in patients with ASDH, this therapy is justified because hematoma irrigation with trephination therapy has a poor outcome for comatose patients. CONCLUSION: Awareness of intraoperative brain swelling is important, as it suggests the development of contralateral hematoma. Immediate computed tomography and a rapid return to the operating room are therefore critical.     

急性肝功能衰竭肝移植手术时机的探讨及预后分析

目的 探讨急性肝功能衰竭患者行肝移植的手术时机及预后影响因素.方法 回顾性分析中山大学附属第一医院2005年3月至2010年6月收治的50例因急性肝功能衰竭行肝移植手术患者的临床资料.按手术效果分为预后良好组和预后不良组,总结术前临床及生化等指标分别行单因素及多因素分析,筛选与围手术期死亡相关的危险因素,指导手术时机的选择.结果 50例行肝移植术的患者中,围手术期死亡11例,分别死于肺部感染5例、肾功能衰竭3例、原发性移植物无功能1例、消化道出血1例、多器官功能衰竭1例.围手术期、术后1、3年生存率分别为78％、74％、72％.单因素分析提示患者年龄、总胆红素、凝血酶原时间、INR、肌酐、肝性脑病分期、MELD评分在预后良好组和预后不良组之间存在显著差异;多因素分析提示年龄≥65岁、INR≥3.5、肌酐≥2.5 mg/dl、MELD≥40分是影响围手术期预后的独立危险因素.结论 肝移植是治疗急性肝功能衰竭的有效办法,把握恰当的手术时机可使患者获得较高的生存率.     

手术方式对不同腹腔转移类型胃癌预后的影响

目的 比较手术方式对不同腹腔转移类型胃癌预后的影响.方法 本组胃癌伴腹腔转移150例,按转移部位不同分为腹膜种植组(106例)、肝转移组(19例)、腹膜种植并肝转移组(25例).手术方法包括病灶全切除、病灶姑息切除、非病灶切除术,部分病例行淋巴结清扫.结果 腹膜种植组、肝转移组、腹膜种植并肝转移组的病灶全切除率分别为48.1%、63.2%和20.0%,淋巴结清扫率分别为48.1%、68.4%和20.0%,腹膜种植组和肝转移组显著高于腹膜种植并肝转移组(P<0.05),腹膜种植并肝转移组以病灶姑息切除(48.0%)和非淋巴结清扫术(80.0%)为主.腹膜种植组、肝转移组、腹膜种植并肝转移组的平均生存期分别为31.1、12.8、9.7个月,腹膜种植组预后最好,腹膜种植并肝转移组最差(P<0.05).腹膜种植组接受病灶全切除、病灶姑息切除、非病灶切除的平均生存期分别为46.3、17.7、4.8个月,各组之间差异均有统计学意义(P<0.05);肝转移组病灶全切除、病灶姑息切除、非病灶切除的平均生存期分别为17.2、4.0、5.4个月,病灶全切除能显著延长患者生存期(P<0.05);腹膜种植并肝转移组行病灶全切除、病灶姑息切除、非病灶切除的平均生存期分别为11.2、8.9、5.0个月,差异均无统计学意义(P>0.05).淋巴结清扫可显著延长腹膜种植组的生存期(P<0.05).结论 胃癌发生腹膜种植患者的预后比发生肝转移患者的好,病灶切除和规范的淋巴结清扫可改善腹膜种植或肝转移胃癌患者的预后.     

Intracranial hypotension with subdural hematoma following lumbar puncture: case report

BACKGROUND AND PURPOSE: Lumbar puncture is a common procedure highly contributive to neurological diagnosis. It can also cause serious adverse side effects including subdural hematoma and intracranial hypotension as illustrated by this case report. CASE REPORT: A 38-year-old women presented severe intracranial hypotension after a lumbar puncture. Magnetic resonance imaging was compatible with intracranial hypotension and revealed an acute subdural hematoma with midline deviation. A first blood patch was unsuccessful. Symptom relief was achieved with a second patch. The patient was, then, discharged but developed recurrent headache subsequent to the transformation from acute to chronic subdural hematoma. Surgical drainage was required. The postoperative imaging and physical examination returned to normal and the patient was discharged with no recurrence. CONCLUSION: The serious adverse effects of lumbar puncture is an easy and common medical procedure that must be kept in mind.